Systems and methods for posterior dynamic stabilization of the spine

ABSTRACT

Devices, systems and methods for dynamically stabilizing the spine are provided. The devices include an expandable spacer or member having an unexpanded configuration and an expanded configuration, wherein the expandable member in an expanded configuration has a size, volume and/or shape configured for positioning between the spinous processes of adjacent vertebrae in order to distract the vertebrae relative to each other. The systems include one or more expandable members and an expansion medium for injection within or for filling the interior of the expandable member via the port. The methods involve the implantation of one or more devices or expandable spacers.

FIELD OF THE INVENTION

The present invention is directed towards the treatment of spinaldisorders and pain. More particularly, the present invention is directedto systems and methods of treating the spine, which eliminate pain andenable spinal motion, which effectively mimics that of a normallyfunctioning spine.

BACKGROUND OF THE INVENTION

FIG. 1 illustrates a portion of the human spine having a superiorvertebra 2 and an inferior vertebra 4, with an intervertebral disc 6located in between the two vertebral bodies. The superior vertebra 2 hassuperior facet joints 8 a and 8 b, inferior facet joints 10 a and 10 b,posterior arch 16 and spinous process 18. Pedicles 3 a and 3 binterconnect the respective superior facet joints 8 a, 8 b to thevertebral body 2. Extending laterally from superior facet joints 8 a, 8b are transverse processes 7 a and 7 b, respectively. Extending betweeneach inferior facet joints 10 a and 10 b and the spinous process 18 arelamina 5 a and 5 b, respectively. Similarly, inferior vertebra 4 hassuperior facet joints 12 a and 12 b, superior pedicles 9 a and 9 b,transverse processes 11 a and 11 b, inferior facet joints 14 a and 14 b,lamina 15 a and 15 b, posterior arch 20, spinous process 22.

The superior vertebra with its inferior facets, the inferior vertebrawith its superior facet joints, the intervertebral disc, and sevenspinal ligaments (not shown) extending between the superior and inferiorvertebrae together comprise a spinal motion segment or functional spineunit. Each spinal motion segment enables motion along three orthogonalaxes, both in rotation and in translation. The various spinal motionsare illustrated in FIGS. 2A-2C. In particular, FIG. 2A illustratesflexion and extension motions and axial loading, FIG. 2B illustrateslateral bending motion and FIG. 2C illustrated axial rotational motion.A normally functioning spinal motion segment provides physiologicallimits and stiffness in each rotational and translational direction tocreate a stable and strong column structure to support physiologicalloads.

Traumatic, inflammatory, metabolic, synovial, neoplastic anddegenerative disorders of the spine can produce debilitating pain thatcan affect a spinal motion segment's ability to properly function. Thespecific location or source of spinal pain is most often an affectedintervertebral disc or facet joint. Often, a disorder in one location orspinal component can lead to eventual deterioration or disorder, andultimately, pain in the other.

Spine fusion (arthrodesis) is a procedure in which two or more adjacentvertebral bodies are fused together. It is one of the most commonapproaches to alleviating various types of spinal pain, particularlypain associated with one or more affected intervertebral discs. Whilespine fusion generally helps to eliminate certain types of pain, it hasbeen shown to decrease function by limiting the range of motion forpatients in flexion, extension, rotation and lateral bending.Furthermore, the fusion creates increased stresses on adjacent non-fusedmotion segments and accelerated degeneration of the motion segments.Additionally, pseudarthrosis (resulting from an incomplete orineffective fusion) may not provide the expected pain-relief for thepatient. Also, the device(s) used for fusion, whether artificial orbiological, may migrate out of the fusion site creating significant newproblems for the patient.

Various technologies and approaches have been developed to treat spinalpain without fusion in order to maintain or recreate the naturalbiomechanics of the spine. To this end, significant efforts are beingmade in the use of implantable artificial intervertebral discs.Artificial discs are intended to restore articulation between vertebralbodies so as to recreate the full range of motion normally allowed bythe elastic properties of the natural disc. Unfortunately, the currentlyavailable artificial discs do not adequately address all of themechanics of motion for the spinal column.

It has been found that the facet joints can also be a significant sourceof spinal disorders and debilitating pain. For example, a patient maysuffer from arthritic facet joints, severe facet joint tropism,otherwise deformed facet joints, facet joint injuries, etc. Thesedisorders lead to spinal stenosis, degenerative spondylolithesis, and/oristhmic spondylotlisthesis, pinching the nerves that extend between theaffected vertebrae.

Current interventions for the treatment of facet joint disorders havenot been found to provide completely successful results. Facetectomy(removal of the facet joints) may provide some pain relief; but as thefacet joints help to support axial, torsional, and shear loads that acton the spinal column in addition to providing a sliding articulation andmechanism for load transmission, their removal inhibits natural spinalfunction. Laminectomy (removal of the lamina, including the spinal archand the spinous process) may also provide pain relief associated withfacet joint disorders; however, the spine is made less stable andsubject to hypermobility. Problems with the facet joints can alsocomplicate treatments associated with other portions of the spine. Infact, contraindications for disc replacement, include arthritic facetjoints, absent facet joints, severe facet joint tropism, or otherwisedeformed facet joints due to the inability of the artificial disc (whenused with compromised or missing facet joints) to properly restore thenatural biomechanics of the spinal motion segment.

While various attempts have been made at facet joint replacement, theyhave been inadequate. This is due to the fact that prosthetic facetjoints preserve existing bony structures and therefore do not addresspathologies that affect facet joints themselves. Certain facet jointprostheses, such as those disclosed in U.S. Pat. No. 6,132,464, areintended to be supported on the lamina or the posterior arch. As thelamina is a very complex and highly variable anatomical structure, it isvery difficult to design a prosthesis that provides reproduciblepositioning against the lamina to correctly locate the prosthetic facetjoints. In addition, when facet joint replacement involves completeremoval and replacement of the natural facet joint, as disclosed in U.S.Pat. No. 6,579,319, the prosthesis is unlikely to endure the loads andcycling experienced by the vertebra. Thus, the facet joint replacementmay be subject to long-term displacement. Furthermore, when facet jointdisorders are accompanied by disease or trauma to other structures of avertebra (such as the lamina, spinous process, and/or transverseprocesses) facet joint replacement is insufficient to treat theproblem(s).

Most recently, surgical-based technologies, referred to as “dynamicposterior stabilization,” have been developed to address spinal painresulting from more than one disorder, when more than one structure ofthe spine have been compromised. An objective of such technologies is toprovide the support of fusion-based implants while maximizing thenatural biomechanics of the spine. Dynamic posterior stabilizationsystems typically fall into one of two general categories: posteriorpedicle screw-based systems and interspinous spacers.

Examples of pedicle screw-based systems are disclosed in U.S. Pat. Nos.5,015,247, 5,484,437, 5,489,308, 5,609,636 and 5,658,337, 5,741,253,6,080,155, 6,096,038, 6,264,656 and 6,270,498. These types of systemsinvolve the use of screws that are positioned in the vertebral bodythrough the pedicle. Certain types of these pedicle screw-based systemsmay be used to augment compromised facet joints, while others requireremoval of the spinous process and/or the facet joints for implantation.One such system, the Zimmer Spine Dyncsys® employs a cord which isextended between the pedicle screws and a fairly rigid spacer which ispassed over the cord and positioned between the screws. While thissystem is able to provide load sharing and restoration of disc height,because it is so rigid, it does not effective in preserving the naturalmotion of the spinal segment into which it is implanted. Other pediclescrew-based systems employ articulating joints between the pediclescrews. Because these types of systems require the use of pediclescrews, implantation of the systems are often more invasive to implantthan interspinous spacers.

Where the level of disability or pain to the affected spinal motionsegments is not that severe or where the condition, such as an injury,is not chronic, the use of interspinous spacers are preferred overpedicle based systems as they require a less invasive implantationapproach and less dissection of the surrounding tissue and ligaments.Examples of interspinous spacers are disclosed in U.S. Pat. Nos. Re.36,211, 5,645,599, 6,695,842, 6,716,245 and 6,761,720. The spacers,which are made of either a hard or compliant material, are placedbetween adjacent spinous processes. The harder material spacers arefixed in place by means of the opposing force caused by distracting theaffected spinal segment and/or by use of keels that anchor into thespinous process. The more compliant or flexible spacers employartificial ligaments that are wrapped around the spinous processes ofthe vertebrae above and below the level where the spacer is implanted.While slightly less invasive than the procedure required for implantinga pedicle screw-based dynamic stabilization system, the implantation ofinterspinous spacers still require muscle and supraspinous andinterspinous ligament dissection.

With the limitations of current spine stabilization technologies, thereis clearly a need for an improved means and method for dynamic posteriorstabilization of the spine that address the drawbacks of prior devices.In particular, it would be highly beneficial to have a dynamicstabilization system that involves a minimally invasive implantationprocedure, where the extent of distraction between the affectedvertebrae is adjustable upon implantation and at a later time ifnecessary. It would be additionally advantageous if the system or devicewas also removable in a minimally invasive manner.

SUMMARY OF THE INVENTION

The present invention provides devices, systems and methods forstabilizing at least one spinal motion segment. The devices include anexpandable spacer or member having an unexpanded configuration and anexpanded configuration, wherein the expandable member in an expandedconfiguration has a size, volume and/or shape configured for positioningbetween the spinous processes of adjacent vertebrae in order to distractthe vertebrae relative to each other. The expandable member may beballoon made of either non-compliant or compliant material, or mayinclude a mesh material which may be coated or lined with a non-porousmaterial. The device may further include a port for coupling to a sourceof an inflation and/or expansion medium for inflating and/or expandingthe expandable member. In certain embodiments, the port may be used todeflate or evacuate the expandable member. The devices may furtherinclude one or more tabs for anchoring the expandable member to thespinous processes. Optionally, the device may include one marker on asurface of the expandable member to facilitate fluoroscopic imaging.

The invention further includes systems for stabilizing at least onespinal motion segment which include one or more expandable members andan expansion medium for injection within or for filling the interior ofthe expandable member via the port. The subject systems may furtherinclude at least one means for anchoring or securing the expandablemember to the spinal motion segment.

The invention further includes methods for stabilizing at least onespinal motion segment which involve the implantation of one or moredevices or expandable spacers of the present invention, in which theexpandable member is positioned between the spinous processes ofadjacent vertebrae in an unexpanded condition and then subsequentlyexpanded to a size and/or shape for selectively distracting the adjacentvertebrae. The invention also contemplates the temporary implantation ofthe subject devices which may be subsequently removed from the patientonce the intended treatment is complete. Many of the methods involve thepercutaneous implantation of the subject devices.

These and other objects, advantages, and features of the invention willbecome apparent to those persons skilled in the art upon reading thedetails of the invention as more fully described below.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention is best understood from the following detailed descriptionwhen read in conjunction with the accompanying drawings. It isemphasized that, according to common practice, the various features ofthe drawings are not to-scale. On the contrary, the dimensions of thevarious features are arbitrarily expanded or reduced for clarity.Included in the drawings are the following figures:

FIG. 1 illustrated s perspective view of a portion of the human spinehaving two vertebral segments.

FIGS. 2A, 2B and 2C illustrate left side, dorsal and top views,respectively, of the spinal segments of FIG. 1A under going variousmotions.

FIG. 3A illustrates an interspinous device of the present invention inan unexpanded or collapsed state coupled to a cannula of the deliverysystem of the present invention. FIG. 3B is an enlarged view of theinterspinous device of FIG. 3A.

FIG. 4A illustrates an interspinous device of the present invention inan expanded state coupled to a cannula of the delivery system of thepresent invention. FIG. 4B is an enlarged view of the interspinousdevice of FIG. 4A.

FIGS. 5A-5C illustrates top, dorsal and side views of an initial step ofthe method of the present invention in which a cannula is delivered tothe target implant site.

FIGS. 6A and 5B illustrate dorsal and side views of the step ofdissecting an opening within the spinous ligament utilizing a cuttinginstrument of the system of FIGS. 3 and 4. FIG. 6C is an enlarged viewof the target area within the spinous ligament.

FIGS. 7A and 7B illustrate dorsal aid side views of the step ofinserting the interspinous device of FIG. 4A into the dissected openingof the spinous ligament. FIGS. 7C and 7D are enlarged views of thetarget area in FIGS. 7A and 7B, respectively.

FIGS. 8A and 8B illustrate dorsal aid side views of the step ofinflating or expanding the interspinous device of FIG. 4A within theimplant site. FIGS. 8C and 8D are enlarged views of the target area inFIGS. 8C and 8D, respectively.

FIG. 9A illustrates a side view of the step of filling the interspinousdevice of FIG. 4A with an expansion medium. FIG. 9B is an enlarged viewof the target area in FIG. 9A.

FIG. 10A illustrates a dorsal view of the step of further securing theinterspinous device of FIG. 4A within the implant site. FIG. 10B is anenlarged view of the target area in FIG. 10A.

FIGS. 11A and 11B illustrate dorsal aid side views of the step ofinserting another embodiment of an interspinous device into thedissected opening of the spinous ligament. FIGS. 11C and 11D areenlarged views of the target area in FIGS. 11A and 11B, respectively.

FIGS. 12A and 12B illustrate dorsal aid side views of the step ofexpanding the interspinous device of FIGS. 11A-11D within the implantsite. FIGS. 12C and 12D are enlarged views of the target area in FIGS.12A and 12B, respectively.

FIG. 13A illustrates a side view of the step of filling the interspinousdevice of FIGS. 11A-11D with an expansion medium. FIG. 13B is anenlarged view of the target area in FIG. 13A.

DETAILED DESCRIPTION OF THE INVENTION

Before the subject devices, systems and methods are described, it is tobe understood that this invention is not limited to particularembodiments described, as such may, of course, vary. It is also to beunderstood that the terminology used herein is for the purpose ofdescribing particular embodiments only, and is not intended to belimiting, since the scope of the present invention will be limited onlyby the appended claims.

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs.

It must be noted that as used herein and in the appended claims, thesingular forms “a”, “an”, and “the” include plural referents unless thecontext clearly dictates otherwise. Thus, for example, reference to “aspinal segment” may include a plurality of such spinal segments andreference to “the screw” includes reference to one or more screw andequivalents thereof known to those skilled in the art, and so forth.

Where a range of values is provided, it is understood that eachintervening value, to the tenth of the unit of the lower limit unlessthe context clearly dictates otherwise, between the upper and lowerlimits of that range is also specifically disclosed. Each smaller rangebetween any stated value or intervening value in a stated range and anyother stated or intervening value in that stated range is encompassedwithin the invention. The upper and lower limits of these smaller rangesmay independently be included or excluded in the range, and each rangewhere either, neither or both limits are included in the smaller rangesis also encompassed within the invention, subject to any specificallyexcluded limit in the stated range. Where the stated range includes oneor both of the limits, ranges excluding either or both of those includedlimits are also included in the invention.

All publications mentioned herein are incorporated herein by referenceto disclose and describe the methods and/or materials in connection withwhich the publications are cited. The publications discussed herein areprovided solely for their disclosure prior to the filing date of thepresent application. Nothing herein is to be construed as an admissionthat the present invention is not entitled to antedate such publicationby virtue of prior invention. Further, the dates of publication providedmay be different from the actual publication dates which may need to beindependently confirmed.

The present invention will now be described in greater detail by way ofthe following description of exemplary embodiments and variations of thedevices and methods of the present invention. The invention generallyincludes an interspinous spacer device as well as instruments for thepercutaneous implantation of the interspinous spacer. A key feature ofthe interspinous spacer device is that it is expandable from a lowprofile configuration to a higher profile or operative configuration.This design allows the device, when in the low profile condition, to bedelivered by percutaneous means without requiring the removal of anyportion of the spinal motion segment into which the device is implanted.

Referring now to the drawings and to FIGS. 3 and 4 in particular, anexemplary interspinous spacer device 24 of the present invention isillustrated in collapsed and expanded configurations, respectively.Interspinous device 24 includes an expandable spacer body 4 that has asize and shape when in the expanded condition for operative positioningbetween the spinous processes of adjacent superior and inferiorvertebrae of the spinal motion segment being treated. Expandable body 34is made of an expandable or inflatable biocompatible material such asnon-porous material, e.g., latex, acrylate or a metal mesh, e.g., anitinol or titanium cage.

Those spacers made of an inflatable non-porous material, i.e., balloontype spacers (see FIGS. 3-10), are inflated with an inflation orexpansion medium, such as air, saline, another biologically compatiblefluid, or a flowable solid material, such as polyurethane, or a gel,which thickens or hardens substantially upon injection into balloon 34.In one embodiment, balloon 34 is initially inflated with air to providesome structure or rigidity to it to facilitate its optimum positioningand alignment between the spinous processes. Once positioned as desired,balloon 34 is injected with a flowable solid material (the air thereinbeing displaced possibly via a vent hole within port 32). In certainembodiments, the expandable body is made of a non-compliant orsemi-compliant material so as to maintain a substantially fixed shape orconfiguration and ensure proper, long-term retention within the implantsite. In other embodiments, the expandable member may be made of acompliant material. In any embodiment, the compressibility andflexibility of balloon 34 can be selected to address the indicationsbeing treated.

Other embodiments of the subject spacers are made of an expandable meshor cage (see FIGS. 11-12). The mesh or cage maybe made of asuper-elastic memory material which is compressible for delivery througha cannula and which is self-expanding upon implantation. Upon expansion,the mesh or cage may be self-retaining whereby its struts, links orwires are sufficiently rigid by themselves to maintain the expandedcondition and withstand the natural forces exerted on it by spine. Themesh or cage may have an exterior coating or an interior lining made ofmaterials similar to or the same as that used for the balloon spacers,or may otherwise be embedded in such material. In certain embodiments,an expansion medium may be used to fill the interior of the cage or meshstructure, such as with a biologically compatible fluid or flowablesolid material used with the balloon-type embodiments.

In certain embodiments of present invention, either during the implantprocedure or in a subsequent procedure, the size or volume of theimplanted expandable spacer may be selectively adjusted or varied. Forexample, after an initial assessment upon implant, it may be necessaryto adjust, either reduce or increase, the size or volume of the spacerto optimize the intended treatment. Further, it may be intended to onlytemporarily implant the spacer for the purpose of treating a temporarycondition, e.g., an injured or bulging or herniated disk. Once therepair is achieved or the treatment completed, the spacer may beremoved, either with or without substantially reducing the size orvolume of the spacer. In other embodiments, the spacer as well as theinflation/expansion material may be made of biodegradable materialswherein the spacer degrades after a time in which the injury is healedor the treatment completed.

When unexpanded or deflated, as shown in FIGS. 3A and 3B (balloon type)and in FIGS. 11C and 11D (mesh type) expandable body 34 has a lowprofile, such as a narrow, elongated shape, to be easily translatedthrough a delivery cannula 70. The shape of expandable body 34, when inan expanded or inflated state, has larger profile which is generallyH-shaped. Expandable body 34 has lateral or side portions 30, endportions 26 and apexes 28 defined between the side portions 30 and theend portions 26. End portions 26 are preferably recessed or contoured toprovide a narrowed central portion along the height dimension or majoraxis of expandable body 34 to readily fit between and to conform to thespinous processes. Accordingly, expandable body 34 has an apex-to-apexdimension (i.e., height or major axis dimension) from about 3 to about 5cm and a width dimension (minor axis dimension) from about 2 to about 4cm

For those embodiments of expandable bodies which comprise a balloonconfiguration, balloon 34 has an inflation or injection port 32 at asidewall 30 for coupling to a source of inflation or expansion materialor medium. Port 32 may consist of a one-way valve which is self-sealingupon release from an inflation mechanism or tube 76. Port 32 is furtherconfigured to releasably engage from tube 76, where such engagement maybe threaded or involve a releasable locking mechanism. Where theexpandable body comprises a mesh or cage, port 32 simply acts as an exitport, however, where an expansion material is used, it also functions asan injection port for the expansion material.

Optionally, device 24 may include a pair of tabs 36 which may bepositioned on one side of the device where the tabs 36 are preferablysituated at the apexes 28 of expandable body 34. Pins or screws (not yetshown) may be used to secure the tabs against the spinous process tofurther ensure long-term retention of device 24 within the implant site.Tabs 36 are made of a biocompatible material, such as latex, acrylate,rubber, or a metal, and may be made of the same material used for theexpandable member 34. Shown here attached to tabs 36 are tethers 38which are used in part to manipulate the positioning of expandable body34 upon implantation into the targeted spinal motion segment. Thetethers may be made of any suitable material including but not limitedto materials used to make conventional sutures. They may also be made ofa biodegradable material. While two tabs and associated tethers areprovided in the illustrated embodiment, one, three or more may beemployed, where the respective tabs are located on the expandable bodyso as to be adjacent a bony structure of the vertebra suitable foranchoring thereto. In embodiments which do not employ securing tabs 36,tethers 38 may be attached directly to the expandable body itself.

Optionally still, device 24 may further include radiopaque markers 40 onthe surface of expandable body 34 visible under fluoroscopic imaging tofacilitate positioning of the expandable body. Any number of markers 40may be employed anywhere on expandable body 34, however, as few as fourmarkers, one at each apex, may be sufficient. With embodiments employingcage or mesh expandable bodies, the cage or mesh material itself may beradiopaque.

A system of the present invention includes a cannula device 70 having anouter sheath 72, a proximal hub 78 and preferably at least two interiorlumens 74, 76 for the percutaneous delivery the device and other toolsfor implanting the device, which tools may include a cutting instrument62 (see FIG. 6C), a device delivery instrument 76, an endoscope, etc.,which tools will be further discussed in the context of the descriptionof the subject methods with reference to FIGS. 5-10.

In FIGS. 5A-5C, the spinal motion segment of FIG. 1 is illustratedhaving spinal ligament 54 extending between the superior spinous process18 and the inferior spinous process 22. A percutaenous puncture is madeinto the skin 30 adjacent the target spinal motion segment of a patientundergoing the implantation of the interspinous device of the presentinvention, and a cannula 70 is penetrated to the spinous ligament 54.The puncture and subsequent penetration may be made by way of a sharpdistal tip of cannula 70 or by a trocar (not shown) delivered through alumen of cannula 70.

As illustrated in FIGS. 6A-6C, the spinous ligament 54 is then dissectedand an opening 58 created therein by way of a cutting instrument 60,such as a simple scalpel, an electrosurgical device or the like,delivered through a lumen of cannula 70. Cutting instrument 60 may thenbe removed from cannula 70 and, as illustrated in FIGS. 7A-7D (balloontype) and in FIGS. 11A-11D (cage type), a delivery instrument 16 havinginterspinous device 24 operatively preloaded is delivered throughcannula 70.

The preloading of device 24 to delivery instrument 76 involves providingexpandable body 34 in an unexpanded or deflated state and releasablycoupled, as described above, by way of inflation or injection port 32 ofexpandable body 34 to the distal end of delivery instrument 76. Inaddition to functioning as a pusher, instrument 76 may act as aninflation lumen for balloon type embodiments through which an inflationmedium is transported to within expandable body 34.

Depending upon the material used to fabricate expandable body 34, theexpandable body may have a degree of stiffness in an unexpanded ordeflated state such that it may maintain an elongated configuration soas to be directly insertable and pushable through cannula 70. This maythe case where the expandable member 34 is made of a cage or meshmaterial. Alternatively, a pusher or small diameter rod (not shown) maybe inserted through inflation port 32 to within expandable body 34 tokeep it in an elongated state so as to prevent expandable body 4 frombunching within cannula 70 and to provide some rigidity to moreeffectively position the expandable body in the target implant site. Therod is then removed from expandable body 34 and from delivery device 76upon positioning the expandable body at the target implant site. Ineither case, expandable body 34 is folded or compressed about its minoraxis with the side wall opposite the inflation port 32 defining a distalend 25 (see FIG. 3B) and the apexes 28 of the expandable body foldedproximally of distal end 25 to provide a streamline, low profileconfiguration for delivery through cannula 70.

Once interspinous device 24 is preloaded to delivery device 76 as justdescribed, device 24 is then inserted into a lumen of cannula 70 withtethers 38 pulled back and trail proximally so that the tether ends 38 aextend from hub 78 of cannula 70. Expandable body member 34 istranslated through cannula 70 to within opening 58 within spinousligament 54 as best illustrated in FIGS. 7C and 11C. For best results,expandable body 34 is centrally positioned within opening 58 so that thecountered ends 26 of expandable body 34 readily engage with the opposedspinous processes 18, 22. Fluoroscopy may be employed to visualizemarkers 40 so as to ensure that expandable body 34 centrally straddlesthe spinous ligament opening 58, i.e., the markers on the distal side 25of the expandable body are positioned on one side of the spine and themarkers on the proximal side of the expandable body (the side on whichport 32 is located) are positioned on the other side of the spine.

Once centrally positioned, expandable body 34 is inflated or expanded,as illustrated in FIGS. 8A-8D and 12A-12D. For balloon spacers,inflation occurs by allowing an inflation or expansion medium, asdiscussed above, to enter into the interior of the expandable body viaport 32. For expandable mesh spacers, the expandable body may beconfigured to expand automatically upon exiting cannula 70. Theinflation or expansion of expandable body 34 may also be visualizedunder fluoroscopy whereby markers 40, as best shown in FIG. 8C, areobserved and the position of expandable body 34 may be adjusted toensure optimum positioning upon complete inflation. Adjustments of theexpandable body's position may be accomplished by manually pulling onone or both tether ends 38 a which in turn pulls on tabs 26 to which thetethers 38 are attached at their proximal ends. The tethers 38 areselectively pulled as necessary to center or optimally positioninterspinous expandable body 34 to achieve the desired treatment of thetargeted spinal motion segment.

With embodiments in which the expandable body is initially inflated withair and then filled with a solid or fluid medium, the latter ispreferably not delivered or injected into the interior of the expandablebody until the position of the expandable body within the interspinousspace has been verified and optimized. This is beneficial in situationswhere, upon inflation, it is found that the expandable body ismisaligned within the interspinous space and requires repositioning. Theexpandable body may simply be deflated of air to the extent necessaryand repositioned in a less inflated or deflated state. If necessary, forexample where it is found that the maximum spacer or expandable bodysize is insufficient for the particular application at hand, expandablebody 34 may be completely deflated and removed and replaced with a moresuitably sized unit.

For balloon spacers and those mesh spacers which are not by themselvessufficiently self-retaining, once the position and extent of inflationor expansion of expandable body 34 are optimized, the expansion medium,e.g., polyurethane, is allowed to flow or injected into the interior ofthe expandable body via port 32. As illustrated in FIGS. 9A and 9B,expandable body 34 is caused to expand to a selected volume and in sodoing forces apart (see arrow 80) the spinous processes 18, 22 inbetween which it is situated. This selective distraction of the spinousprocesses also results in distraction of the vertebral bodies 2, 4 (seearrow 82) which in turn allows the disk, if bulging or distended, toretract to a more natural position (see arrow 84). Again, the extent ofdistraction or lordosis undergone by the subject vertebrae can bemonitored by observing expandable body markers 40 under fluoroscopy.

The extent of possible distraction maybe limited by the capacity ofexpandable body 34 and the type of expandable body material employed. Incertain embodiments, such as expandable bodies made of non-compliant orsemi-compliant balloons, the requisite volume of the inflation mediummay be substantially fixed whereby the balloon achieves its fullyexpanded configuration upon filling it with the fixed volume of medium.In other embodiments, such as with balloons made of a compliantmaterial, the extent of expansion may be variable and selectableintraoperatively depending on the extent of lordosis or distraction tobe achieved between the spinous processes in which balloon 34 is nowinterposed.

Upon achieving the desired distraction between the vertebrae,inflation/expansion lumen 76 is disengaged from expandable body port 32which then becomes sealed by means of a one-way valve that is closedupon disengagement of lumen 76. Inflation/expansion lumen is thenremoved from cannula 70. While the opposing compressive force exerted onexpandable body 34 by the distracted spinous processes 18, 22 may besufficient to permanently retain expandable body 34 therebetween, theinterspinous device may be further secured to the spinous processes 18,22 to ensure that the expandable body does not slip or migrate from itsimplanted position. To this end, tabs 36 are anchored to the spinousprocesses as illustrated in FIGS. 10A and 10B and in FIGS. 13A and 13B.Any type of anchoring means, such as screws, tacks, staples, adhesive,etc. may be employed to anchor tabs 36. Here, cannulated screws 90 areused as anchors and are delivered to the target site releasably coupledto screw driving instrument 88. While various screw attachment andrelease mechanisms may be employed, a simple configuration involvesproviding the screws 90 with a threaded inner lumen which is threadablyengagable with the threaded distal end of instrument 88.

To ensure accurate placement of screws 90, along with instrument 88, canbe tracked and translated over respective tethers 38, which function asguide wires. By manipulating instrument 88, the screws are driven orscrewed into the respective spinous process. Screwdriver 88 is thendisengaged or unscrewed from screw 90. After both tabs 36 are securelyanchored to the spinous processes, the screwdriver and the cannula maybe removed from the patient's back.

While certain of the expandable spacers are intended to be permanentlyimplanted within a spine, certain others may be implanted onlytemporarily to facilitate the healing of an injury or the treatment of areversible or non-chronic condition, such as a herniated disk. For suchtemporary treatments, the expansion material most likely is a fluid,such as saline, which may be easily aspirated through port 32 or may beallowed to drain out via a penetration or cut made in the expandablemember. In those embodiments in which the expansion material is aflowable solid, which may or may not subsequently harden within theexpandable member, the material may be one that is reconstitutable intoa liquid form which may then be subsequently aspirated or evacuated fromthe expandable member. For percutaneous removal of the expandablemember, a cannula such as cannula 70 may be used and an aspirationinstrument delivered therethrough and coupled to port 32. Afterdeflation and/or evacuation of the expandable member, and removal of thetacks, sutures, staples, etc. if such are used to secure tabs 36, theexpandable member may be easily removed through cannula 70. Withbiodegradable spacers, removal of the spacer is obviated.

It should be noted that any of the above-described steps or procedures,including but not limited to cannulation of the target area, dissectionof the spinous ligament, insertion of the expandable body within thedissected opening of the spinous ligament, inflation and/or expansion ofthe expandable body, adjustment or readjustment of the expandable body,and anchoring of the tabs, etc., may be facilitated by way of a scope 62delivered through a lumen of cannula 70 to the open distal tip ofcannula 70. Alternatively, a second cannula delivered through anotherpercutaneous penetration may be employed for use of an endoscope and anyother instruments needed to facilitate the procedure.

The subject devices and systems may be provided in the form of a kitwhich includes at least one interspinous device of the presentinvention. A plurality of such devices may be provided where the deviceshave the same or varying sizes and shapes and are made of the same orvarying materials. The kits may further include instruments and toolsfor implanting the subject devices, including but not limited to, acannula, a trocar, a scope, a device delivery/inflation/expansion lumen,a cutting instrument, a screw driver, etc., as well as a selection ofscrews or other devices for anchoring the spacer tabs to the spinousprocesses. The kits may also include a supply of the expandable bodyinflation and/or expansion medium. Instructions for implanting theinterspinous spacers and using the above-described instrumentation mayalso be provided with the kits.

The preceding merely illustrates the principles of the invention. Itwill be appreciated that those skilled in the art will be able to devisevarious arrangements which, although not explicitly described or shownherein, embody the principles of the invention and are included withinits spirit and scope. Furthermore, all examples and conditional languagerecited herein are principally intended to aid the reader inunderstanding the principles of the invention and the conceptscontributed by the inventors to furthering the art, and are to beconstrued as being without limitation to such specifically recitedexamples and conditions. Moreover, all statements herein recitingprinciples, aspects, and embodiments of the invention as well asspecific examples thereof, are intended to encompass both structural andfunctional equivalents thereof. Additionally, it is intended that suchequivalents include both currently known equivalents and equivalentsdeveloped in the future, i.e., any elements developed that perform thesame function, regardless of structure. The scope of the presentinvention, therefore, is not intended to be limited to the exemplaryembodiments shown and described herein. Rather, the scope and spirit ofpresent invention is embodied by the appended claims.

1.-30. (canceled)
 31. A method for spacing apart a superior spinousprocess and an inferior spinous process of a subject, the methodcomprising: positioning an interspinous spacer device between thesuperior and inferior spinous processes, the interspinous spacer deviceincluding a main body, a pair of superior elongate members, and a pairof inferior elongate members; moving the interspinous spacer device froma delivery configuration toward a deployed H-shaped configuration usingan instrument coupled to the interspinous spacer device such that thesuperior elongate members rotate relative to the main body and movealong opposite sides of the superior spinous process, the inferiorelongate members rotate relative to the main body and move alongopposite sides of the inferior spinous process, and superior andinferior central sections of the main body move away from one anotherand toward the superior and inferior spinous processes; and separatingthe instrument from the interspinous spacer device after the superiorand inferior central sections extend laterally across the superior andinferior spinous processes, respectively, and the interspinous spacerdevice is in the deployed H-shaped configuration.
 32. The method ofclaim 31, wherein the superior spinous process is held between thesuperior elongate members and the inferior spinous process is heldbetween the inferior elongate members when the instrument is separatedfrom the interspinous spacer device.
 33. The method of claim 31, whereinpositioning the interspinous spacer device between the superior andinferior spinous processes comprises: moving at least a portion of adelivery cannula into the subject; and translating the interspinousspacer device through and out of the delivery cannula.
 34. The method ofclaim 31, wherein positioning the interspinous spacer device between thesuperior and inferior spinous processes comprises: moving an end of acannula into the subject; and moving the interspinous spacer devicealong a lumen of the cannula while the cannula is positioned in thesubject.
 35. The method of claim 34, wherein the interspinous spacerdevice is moved from the delivery configuration toward the deployedH-shaped configuration while the instrument extends through the cannula.36. The method of claim 35, wherein the instrument is configured tocontrollably move the interspinous spacer device from the deliveryconfiguration toward the deployed H-shaped configuration and tocontrollably move the interspinous spacer device from the deployedH-shaped configuration toward the delivery configuration.
 37. The methodof claim 31, wherein the superior and inferior elongate members aresubstantially parallel to a longitudinal axis of the interspinous spacerdevice when the interspinous spacer device is in the deliveryconfiguration.
 38. The method of claim 31, wherein moving theinterspinous spacer device from the delivery configuration toward thedeployed H-shaped configuration includes rotating the superior andinferior elongate members from a collapsed axial configuration to adeployed orthogonal configuration.
 39. The method of claim 31 whereinthe interspinous spacer device comprises a metal H-shaped structure. 40.The method of claim 31, wherein the superior elongate members and thesuperior central section define a U-shape, and wherein the inferiorelongate members and the inferior central section define a U-shape. 41.The method of claim 31, wherein the superior elongate members arefoldable against the main body.
 42. The method of claim 31, furthercomprising: positioning a cannula in the subject; moving a cuttinginstrument through the cannula and into the subject; and cutting tissueof the subject using the cutting instrument to provide access to aninterspinous space between the superior and inferior spinous processes.43. A method for spacing apart a first spinous process and a secondspinous process, the method comprising: positioning an interspinousspacer device at an interspinous space between the first and secondspinous processes; rotating a pair of first elongate members of theinterspinous spacer device from a first delivery configuration toward afirst deployed configuration; rotating a pair of second elongate membersof the interspinous spacer device from a second delivery configurationtoward a second deployed configuration; and separating a deliveryinstrument from the interspinous spacer device when the interspinousspacer device is in a deployed H-shaped configuration and when the firstand second elongate members are in the first and second deployedconfigurations, respectively.
 44. The method of claim 43, whereinpositioning the interspinous spacer device at the interspinous spacecomprises: moving at least a portion of a delivery cannula into thesubject; translating the interspinous spacer device along the deliverycannula which is positioned in the subject; and moving the interspinousspacer device out an end of the delivery cannula which is positioned inthe subject.
 45. The method of claim 43, wherein positioning theinterspinous spacer device between the superior and inferior spinousprocesses comprises: moving an end of a cannula into the subject; andmoving the interspinous spacer device along the cannula and out the endof the cannula.
 46. The method of claim 45, wherein the interspinousspacer device is moved from the delivery configuration toward thedeployed H-shaped configuration while the instrument extends through thecannula.
 47. The method of claim 43, wherein the interspinous spacerdevice comprises a deployable metal H-shaped structure.
 48. The methodof claim 43, further comprising: positioning a cannula in the subject;delivering a cutting instrument through the cannula and into thesubject; and cutting tissue of the subject to provide access to theinterspinous space for positioning the interspinous spacer device at theinterspinous space.